However, it’s important to keep in mind that only one third of individuals have these classic symptoms of intermittent claudication. Furthermore, more than 50% of patients with PAD are asymptomatic (i.e. don’t have any symptoms) or have atypical symptoms.

NATURAL HISTORY OF PAD:

If you go to the doctor because you are experiencing leg cramps from walking and you are diagnosed with PAD, chances are, you will not observe any progression of your symptoms. To quantify, approximately 60% of those with PAD will have no progression of limb symptoms beyond the subsequent 5 years after initial presentation. So that’s the good news. Also, limb loss occurs in a minority of patients. The bad news is that despite the relatively stable prognosis for the affected limb, there is a marked risk of cardiovascular morbidity and mortality during the 5 years after diagnosis of intermittent claudication. The rate of nonfatal cardiovascular events (myocardial infarction and stroke) is 20%, with a 5-year mortality rate of 30%.

PAD is bad regardless of whether it’s causing your leg pain or not. Subjects with asymptomatic PAD appear to have the same risk of cardiovascular events and death seen in patients with intermittent claudication.

For patients with chronic limb ischemia (CLI), the outcomes are significantly worse. In addition to the marked increase in rates of limb loss, 20% of these patients die within 6 months!

After a thorough history and physical exam, the best initial examination to determine if you have PAD is an ankle-brachial index, also known as an ABI. This is found to be the most simple, inexpensive, reliable, and reproducible method of identifying patients with PAD. It’s also painless!!! So don’t hesitate to get an ABI.

What you and your doctor can do to improve your symptoms and decrease your risks

There are many lifestyle modifications that help with both PAD and arterial disease throughout the body. These include:

• Tobacco cessation
• Physical activity
• Dietary modification
• Weight maintenance/reduction.
• Blood pressure control
• Modification of elevated total and LDL cholesterol levels
• Antiplatelet therapy:
• Angiotensin-converting enzyme (ACE) inhibitor therapy
• Glycemic control in patients with diabetes mellitus

So don’t ignore your leg pains! If walking is causing your leg cramps, go see your doctor. Remember that PAD can indicate that you probably have blockages in other arteries and this puts you at a significant risk for heart attack and stroke!

PAD Symptoms
1. Claudication which is intermittent. This is predictable, reproducible muscular pain or fatigue with exercise (most commonly in the calf, but also anywhere in leg). Patients will say things like “after walking 4 blocks, my legs start to hurt and it’s relieved by rest.”
2. Rest pain (foot) which is characteristically relieved by dangling the foot over the edge of the bed.
3. Progressive PAD can eventually lead to ulceration, gangrene, or limb loss.

PAD Risk Factors
1. Male
2. Age over 50
3. Smoking
4. Diabetes
5. Obesity
6. Lack of exercise
7. High blood pressure
8. High cholesterol
9. Family history

Venous Insufficiency Symptoms
1. Pain, throbbing of legs
2. Swelling
3. Aching or heaviness of legs
4. Fatigue
5. Restless Legs
6. Night cramps
7. Varicose veins
8. Spider veins
9. Skin changes (darkening or lightening of the skin, leather-like skin, eczema)
10. Skin ulcers

Pain, swelling, aching, throbbing of legs tend to get worse as the day goes on and improves by elevating the legs. Symptoms may be occasional.

Venous Insufficiency Risk Factors
1. Heredity
2. Female
3. Pregnancy
4. Aging

There are many other possible risks which to date have a weak association with venous insufficiency at best.

If you have any of the above symptoms, visit your doctor. Keep in mind that if you are diagnosed with PAD, that it’s very likely that other important arteries are affected as well such as arteries supplying your heart and your brain. Also keep in mind that if you have venous insufficiency, you no longer need stripping and ligation. Today’s venous procedures can be performed in the office. I would recommend only visiting a doctor who specializes in venous disorders.

Unfortunately, Cindy is not alone. Approximately two-thirds of Americans are considered to be either overweight or obese. While Cindy is not obese, it is worth noting that obesity is the number two cause of preventable death in the United States. It’s hard to imagine that at least 60 million Americans are obese, despite all of the different weight loss programs, diets books, health clubs, fitness classes and videos out there on the market. With that being said, we all know that being overweight or obese increases the risk of health conditions such as breast cancer, coronary artery disease, Type II diabetes, sleep apnea, gallbladder disease, osteoarthritis, colon cancer, hypertension and stroke, just to name a few. These are sobering and costly statistics. It is estimated that obesity among full-time workers costs over 73 billion dollars per year. These costs are related to disabilities, increased need for medical care and death.

As noted above, healthcare workers are not immune to the obesity epidemic. In fact, this is a high-risk workgroup known for physical deterioration and early retirement. For years I have noticed that so many healthcare workers are trying to lose weight. My frustration resides in the fact that these healthcare workers have bought into so many of the great marketing efforts of the food industry. Labels including the terms: low fat; may reduce your risk of heart disease; high in fiber or no high fructose corn syrup are often so very misleading. So ultimately, most of us are eating the wrong things. Furthermore, approximately 3/4 of Americans are not meeting basic activity level recommendations and at least 25% of us are simply couch potatoes. For those who are exercising and not seeing results, I believe the big cause is due to the lack of weight training.

We need to reverse these trends! As physicians, we have a great opportunity to really make a difference. It seems like we could learn a bit from the business community where some corporations encourage employees to exercise during the workday, many offering perks such as wellness coaches, on-site health screenings and fitness programs. Furthermore, 70% of Fortune 200 companies offer physical fitness programs, according to the National Business Group on Health, with many saving on healthcare as a result.

There are approximately 240 million results for the Google search term ‘weight loss’ with 519 million results for the term ‘exercise’. So it’s an understatement to say that there are many options in which to get physically fit. That’s why it’s so important to keep it simple. And that is what we are going to do at our vein clinics for fourteen weeks. Of course, it is my belief that the fourteen weeks will segue into a permanent eating and exercise program.

Our eating plan is easy. It will be a bit difficult for the first four weeks versus the last ten weeks. In the first four, we will go low carb. Ouch! But it’s only temporary so that the digestive system gets a bit of a jump start. During the last ten weeks of our program, we will reintroduce healthy carbs. A very cool and enjoyable part of our “Fourteen Weeks to Fabulous” is that once a week, we will take a day off. One day a week, we get to eat whatever and however much we want. It’s great both psychologically as well as physically.

To be a little more specific on the eating plan, we will eliminate sugar, high fructose corn syrup and starch. Examples of bad starches include bread, rice, potatoes, peas, corn and all of the sugary things like candy, soda and baked goods. My staff has been told to throw away all of their “low fat” snacks (tons of sugar) as well as heavily processed foods, which are chock-full of hidden ingredients. Furthermore, they have been instructed to throw away food if they can’t pronounce the ingredients or if their grandmother wouldn’t know what it was. We will be keeping fruit intake low for the first 4 weeks but like I said, will re-introduce the healthy carbs back towards the end of the regiment. My staff will be allowed to eat all of the carbs they want on days off. As for the “what to eat”, they have been instructed to eat high quality protein in every meal, along with tons of fresh veggies. They are to eat often…5 to 6 times a day. They are replacing their chocolate snacks and candies with a handful of almonds, healthy protein shakes and plenty of vegetables.

As for exercise, we will lift weights three days a week and alternate this with 20 minutes of cardio, for three days. The cardio will be interval training. An example would be:
Monday upper body weight training
Tuesday cardio
Wednesday lower body weight training
Thursday cardio
Friday upper body weight training
Saturday cardio
The following week would begin with lower body weight training on Monday.

At our Novi location, we have received support from Spinal and Orthopedic Rehabilitation (SOR), to allow our staff to use their facilities during work hours. At our Troy location, Dr. Steven Wang took it upon himself to purchase exercise bands for his staff.

References:
1. Cost of Obesity in America: Stats & Analysis, by Marc Perry Jan 20, 2011 http://www.builtlean.com/2011/01/20/cost-of-obesity-in-america-stats-analysis/
2. http://www.cdc.gov/
3. http://articles.latimes.com/2011/may/15/health/la-he-workplace-fitness-20110515
4. Eating for Life. Bill Phillips
5. Mens Health Big Book of Exercise

The ClariVein® device is a single use disposable system that provides a pharmaco-mechanical endovenous ablation treatment. It contains a rotating infusion catheter/wire with an angled tip that protrudes 2 centimeters. The wire rotates, mechanically damaging the endothelial layer of the vein, while at the same time, dispersing sclerosant (vein closing serum) The wire system is connected to a 9V battery–motorized handle unit which controls the wire rotation. There is a 5-mL syringe mounted on the motorized handle which is designed to deliver sclerosant. I had the great privilege to use this device recently.

The ClariVein® Procedure
The ClariVein procedure is not much different from other ablation techniques with the exception of one thing: there is no tumescent anesthesia! Thus, the part of the procedure that takes the longest time and requires multiple needle pokes is eliminated. After the catheter/wire system is placed into the affected vein, sclerosant is slowly injected into the vein, while continuing the pull-back, as the wire is still rotating. This results in a mechanical injuring of the vein while performing the sclerotherapy. This one-two punch combination does a great job in closing down the “bad veins.”

My Experience
Overall, I give the device two thumbs up. I loved not having to use tumescent anesthesia. We treated several patients with the device and experienced no difficulties or complications. At our one week follow up, all treated veins were ablated and there were no DVT’s. All patients tolerated the procedure very well. Of note, one patient had a prior endovenous laser ablation of her contralateral lower extremity. She relayed to us that the ClariVein® was less painful both during and after the procedure.

Potential Advantages…why it might be the next big thing!
The biggest advantage of the ClariVein® device is that tumescent anesthesia is not required. Physicians using the device will be thrilled to eliminate this from endovenous ablations, thus saving time. Patients will love it too, as the tumescent component of EVTA is often the most painful part of the procedure. The lack of heat should diminish, if not eliminate, post procedural parasthesia (temporary nerve injury). Since sclerosant will also “leak” into tributaries, I we may see the need for concurrent microphlebectomy or adjuvant chemical ablation of varicosities diminish.

Current treatments for venous insufficiency and varicose veins do not require hospitalization, general anesthesia, or a prolonged recovery period. Patients typically experience little if any pain and return to work the next day.

With the advent of minimally invasive techniques for the treatment of varicose veins, venous reflux and venous insufficiency, the decision-making process for determination of medical necessity should have changed. When the only option for treatment was surgical ligation and stripping, it was reasonable to consider alternatives such as the use of compression stockings. Older surgical techniques were associated with significant post-operative pain and prolonged recovery periods, not to mention the risk of side effects relaxted to general anesthesia.

The use of graduated compression stockings certainly play a role in modern medicine in regards to assisting in the prevention of deep venous thrombosis and venous ulcers. Compression stockings are also are useful after vein procedures are completed. However, there is absolutely no medical reasoning behind having patients wear these stockings as a prerequisite to insurance coverage for current vein treatments.

So why do insurance companies require the use of compression stockings before varicose vein treatment? Good question!

ref: American College of Phlebology Guidelines for Varicose Vein Surgery As of July 2008.

Symptoms of lymphedema include:

• Swelling
• Aching
• Heaviness or tightness
• Restricted range of motion
• Recurring infections in your affected limb
• Hardening and thickening of the skin

Symptoms of Venous Insufficiency include:

• Swelling
• Throbbing
• Achieness
• Leg Pain

Until recently, there has been little hope for persons suffering from lymphedema. Treatment has been mainly aimed at compressing fluid from the extremity using compression stockings or other compression devices as well as manual decompression treatment. There are also surgeons (mainly in Italy and Australia) that have performed microsurgery to connect the tiny lymphatic vessels to veins in order to relieve the swelling. Recently however, a Swedish surgeon pioneered the use of a novel treatment for chronic lymphedema…liposuction! It has been shown that the excessive lymphatic fluid in an extremity eventually causes the deposition of fat. This fat can then be removed with liposuction. He notes however, that compression stocking treatment after liposuction is critical to continued success. So, if you have leg swelling, I recommend visiting a vein specialist first. Venous insufficiency is the most common cause of swelling. If you are diagnosed with lymphedema, there is at least some new hope!

Ref: Liposuction as a treatment for Lymphoedema
Dr. Hakan Brorson, Dr. Carolin Freccero; eurolymphology.org